A treatise on the prevention and cure of pulmonary consumption

Preface

Every disease incident to the human body should receive a degree of consideration proportionate to its danger, and to the frequency of its occurrence; and, as Pulmonary Consumption is that which is not only the most common, but by far the most fatal in its effects, I think it should occupy the attention of the physician more than any other. Having, for many years past, enjoyed extensive practical opportunities of studying it, I now beg leave to submit to the public the following Treatise, as the result of my experience; and, if the principles which I have therein endeavoured to inculcate shall tend either to the relief of the sufferings, or to the prolongation of the life of my fellow-creatures, I will consider myself amply rewarded for the many years I have laboured to acquire a correct, practical acquaintance with the subject.

The attention paid to the different means necessary for the purpose of preventing the occurrence of Pulmonary Consumption has always appeared to me extremely de¬ fective. I have, therefore, entered into their consideration at much length; and I trust it will be found, that if they are carried into effect in the manner which I have recom¬ mended, there will be a vast reduction in the number of victims to that disease. Although I do not believe that, in every instance, its occurrence would be prevented in these countries by the use of any means which could be employed; yet I am convinced, that in a considerable

VI number, much might be done towards the fulfilment of tliis end, provided those of a suitable nature wTere adopted at an early period of life. It would appear to me, that the want of success which the physician has generally experienced in the prevention of tuberculous disease of the lungs, is owing as much to the necessary treatment not being soon enough carried into effect, as to any inade¬ quacy on its part to establish such a state of the body as would obviate the occurrence of the disease.

With reference to the cure of Pulmonary Consumption, I have endeavoured to prove that it may be accom¬ plished, in a great many instances, by the most simple remedies; but, although this is the case, there are very few patients who will derive any benefit from the curative means employed, because they are neither sufficiently extensive, nor used at a sufficiently early stage of the disease. I think the opinion, that Consumption is in¬ curable at every stage, has been productive of the greatest mischief, inasmuch as it has frequently induced medical men to give up the employment of all remedial measures, and submit the patient to his fate, when there was still a good chance of effecting a cure, had those of a proper kind been used only in a suitable manner. It could not possibly be expected, that the proportion of cures would be very large, no matter how soon, after the formation of the tubercles in the lungs has taken place, the necessary treatment is carried into effect. I think, however, that even a small proportion should be suf¬ ficient to encourage the physician to the greatest activity in the employment of the requisite remedies.

ROBERT LITTLE.

Belfast , February 1, 1836.

CHAP. I. PRELIMINARY OBSERVATIONS ON THE NATURE, CAUSES, SYMPTOMS, &c

OF PULMONARY CONSUMPTION.

Page

Symptoms of Pulmonary Consumjition . . . 28

Complications, Progress, and Termination of Pulmonary Consumption .... 38-

Chap. II. On The Prevention Of Pulmonary Consumption

On the means best calculated, during the foetal and the infant state, for preventing the formation of a constitutional tendency to Pulmonary Consumption, or for removing such tendency when it exists . 45

On the best mode of preventing, during childhood, adolescence, and the succeeding stages of life, the formation of a constitutional disposition to Pulmonary Consumption; and also of preventing the occurrence of the disease when such disposition, whether natural or acquired, exists . 58

Chap. III. On The Cure Of Pulmonary Consumption

On the different remedies which may be most advantageously employed in the treatment of Pulmonary Consumption during its early stage . 83

On the treatment of the most troublesome symptoms which occur during the incipient stage of Pulmonary Consumption . . . 136

On the remedies which are most profitable for the treatment of Pulmonary Consumption during its advanced stage . . . 148

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TREATISE

ON

PULMONARY CONSUMPTION.

Chap. I

PRELIMINARY OBSERVATIONS ON THE NATURE, CAUSES, SYMPTOMS, &c. OF PULMONARY CONSUMPTION.

Nature of Pulmonary Consumption.

When the study of Morbid Anatomy was little attended to, — as was the case for many centuries, even after those obstacles were to a certain extent removed which had been thrown in the way in the ruder ages of the world, — it is not at all wonderful that the diseases of some of the most important organs of the body, though quite different from each other, should have been in very many instances all comprehended under some one term. In proportion as physicians become better acquainted with Morbid Anatomy, in the same proportion they acquire a more correct knowledge of the characters of disease, and, of course, of the symptoms which indicate one diseased condition from those which indicate another. Notwithstanding that the maladies of the lungs have been, for a great length of time, considered amongst the most dangerous from which the human species are liable to suffer; yet it is only within the last few years that medical men have acquired any thing like precise ideas respecting them. It was, for instance, no uncommon thing, not long since, to include under the term

Phthisis Pulmonalis , or Pulmonary Consumption, tubercular for-

A mations, chronic inflammation, and various other diseases of the lungs; so that, instead of applying to the different morbid affec¬ tions to which these organs are liable, certain specific terms, cal¬ culated to point out their nature and seat, the whole were very often confounded together on account of their being accompanied with a wasting of the body — a symptom common to them all.

The confusion and danger produced by the application of im¬ proper terms in medicine, were, for many ages, very great; and I am not acquainted with any one circumstance which has tended so much of late years to improve the physician in the treatment of pulmonary affections, as that of knowing with accuracy for what disease he is prescribing, and what changes he should expect from the remedies which he employs.

Of all the organs which enter into the formation of the human body, the lungs are the most subject to disease; and such is not at all wonderful, when the nature and extent of their functions are duly considered. It is in them that the purification of the blood takes place; and in order to accomplish this, they are not only kept in constant motion, but they are subjected to the greatest variety of impressions on account of the great difference that there is at various seasons of the year, and in different places of the temperature and general physical qualities of the air which circu¬ lates through their numerous tubes and cells for that very im¬ portant purpose.

The term Phthisis Pulmonalis, or Pulmonary Consumption — which was employed for a great length of time in the most vague manner, and without being more applicable, in many instances, to one diseased condition of the lungs than to another — has been, since the time Laennec published his celebrated work on the dis¬ eases of the chest, confined to those of a tuberculous nature.

The formation, growth, and conversion of pulmonary tubercles into a purulent state, are all generally preceded, accompanied, or succeeded by disease of the natural tissues of the lungs; but, as to the amount of disease or the tissue which is most affected, there is the greatest difference in almost every successive case to

Nature of Pulmonary Consumption .

winch the physician directs his attention. It would therefore ap¬ pear, that, although consumption may be considered as a malady proceeding from the development of certain morbid growths in the place of some of the natural tissues or secretions of the lungs; yet it will be found, in every instance, that these organs are also affected with various other diseases in connexion with that of a tuberculous kind. It is, for instance, in the disease in question, a very rare thing not to meet with bronchitis, pneumonia, or pleuritis, either singly or conjointly, at some time during its pro¬ gress; so that different disorganizing processes may be going on at the same time. It is, therefore, from the circumstance of the pul¬ monary organs presenting the most opposite morbid appearances in fatal cases of consumption, not by any means wonderful, that the greatest difficulty should have arisen as to the relation which these had to each other.

Scrofula, of which Pulmonary Consumption is only a parti¬ cular form, may be regarded as one of the most prevalent, and, at the same time, most destructive diseases, incident to the human species, in all cold damp climates, especially when they are subject to sudden changes of temperature, from heat to cold, or from cold to heat. In those countries, however, whose temperature is pretty uniform, no matter whether they be cold or hot, it does not prevail to the same extent, nor is it so very fatal in its effects.

Different attempts have been made to estimate the mortality in various countries from the disease in question, in all the divers forms which it assumes at different ages ; but it is impossible to arrive, respecting this, to any thing like the truth. From the calculations which have been made, it would appear, that in these countries, one fourth of the deaths which occur annually, are from tuberculous disease of the lungs; and that from this, and all the various other forms of scrofula, the mortality is about one third of the whole. I do not think that, taking an average of the number of deaths which take place every year in these countries from tuberculous disease of the lungs, or scrofula, in all its different

Nature of Pulmonary Consumption.

forms, it would be any thing near so high as has been very generally stated. It is mostly in large towns that calculations are made with regard to the comparative mortality from different dis¬ eases ; and when such is the case, the results will be found to be at the greatest variance from what occurs when similar calculations are made in small towns, or in country districts. If I were to speak from what I have observed myself, relative to the comparative mortality from scrofula in all its forms in Belfast and the neigh¬ bouring country, I would say, that it is nearly three times as great in the former as in the latter, in proportion to the popu¬ lation. From the situation of the town just mentioned, and other circumstances connected with it, there would seem to be a complete combination of every thing requisite for the purpose of generating, or bringing into action, tuberculous disease of the lungs, and other forms of scrofula ; and yet, from the calculatations which I have made, for several years past, both at the Hospital and Dispensary, I would not be justified in rating the mortality from Pulmonary Consumption at more than the one eighth ; and from this and the various other forms which scrofula assumes, at more than the one sixth of the entire mor¬ tality occurring in any given time. It has always appeared to me, that a disease, such as I am considering, which is liable to assume such a vast variety of forms, and to affect so many different parts of the system, must necessarily give rise to many errors in any estimates which are made relative to the com¬ parative mortality it occasions. Be this, however, as it may, there is no physician who has had a sufficiently extensive oppor¬ tunity for observation, who could possibly avoid coming to the conclusion, that scrofula, in some form or other, is at least in¬ finitely more prevalent and fatal than any other morbid affection of the system to which he can direct his attention ; and it would appear, that no matter whether his observations may be made in a large town or in a district of country, still he will find the results as to its fatal effects, when compared with other maladies occurring in the same locality, to be proportionably great.

It is a very curious circumstance, that the disease in question should, in many parts of the world, not only prove the most fatal of all others to the human species, but that it should also give rise to the same fatal effects in many of the lower orders of animals, whose physical and vital powers must be all, to a very considerable extent, different from those possessed by man.

It is not only wonderful, that tubercular diseases are liable to occur in many of the lower animals as well as the human species, but that the susceptibility of particular organs to their occurrence should vary as much in one order of beings as in another. The monkey species seem to be more predisposed to these morbid formations, than any of the other lower orders of animals; so that those creatures which are the most closely allied to the human species in point of form, and in all probability also in point of organization, of any of the inferior animals, are the most liable to fall victims to tuberculous disease, but more particularly of the lungs.* It would therefore appear, that man is not the only being that is liable to Consumption, and various other forms of scrofula.

The susceptibility of different parts of the body to tubercular diseases varies very much at different periods of life; so that, while at one time they are of all morbid affections the most com¬ mon, and at the same time the most destructive in their effects to one part, they are least so to another. Although in infancy they sometimes occur in the lungs, the absorbent glands, and various other situations in the body; still such is so very seldom the case, that it would be exceedingly difficult to say, at that period of life, what parts are most liable to their formation. The same, however, is not the case during childhood; for they are then very frequently to be met with; and the absorbent glands would seem, of all the structures of the body, those in which they are by far the most liable to take place. This is the case from one till ten or twelve years of age, and even, in many instances, till fourteen or

* See Andral, Precis d’Anat. Pathologiquc. Dupuy , de V Affection Tuberculeuse.

fifteen. Now, from that period of life when the body has arrived, or nearly arrived, at full maturity, the lungs, instead of the absor¬ bent glands, would appear to be the most frequently affected with the morbid formations in question. It would, in fact, seem that Pulmonary Consumption is of very rare occurrence in either early or advanced life, when compared with what it is from about the age of maturity until the fortieth or forty-fifth year.*

Tubercles present the greatest difference in their appearance in different situations of the body; and this is even the case, in the same situation, at various stages of their growth. In the lungs they are frequently to be met with of not greater size than that of the head of a small pin; and at other times, they will vary in size from that of a pea to a hazel nut. But again, instead of the tubercular matter assuming the round form, it is secreted in large irregular masses, and thus constitutes what has been denominated tubercular infiltration. While there is the greatest variety with respect to the magnitude of these morbid growths, there is also the greatest variety with reference to their colour. They have, for instance, sometimes a semi-transparent aspect, and at other times an opaque. It would appear that their transparency dimi¬ nishes in proportion as they increase in size; so that, after they have acquired a certain degree of development, they gradually begin to assume an opaque appearance. It would, therefore, occur to me that, while they are of a very small size, they are al¬ ways possessed of a degree of transparency. This has been, at least, the case in every instance where I have had an opportunity of investigating the subject at a sufficiently early stage of their growth. In several instances I have had an occasion afforded me

O

of examining recent cases of tubercular infiltration, and I have invariably found the solidified mass to present a considerable

* For a more detailed account of the comparative frequency of the occurrence of tubercles in different parts of the body at different ages, see Andral, Precis d’Anat. Patholog. tome I. Lombard , Essai sur les Tubercles. Louis, Recherches sur la Phthisic.

degree of transparency. The fact is, I am of opinion, if I can judge accurately from the number of patients which I have had an opportunity of examining while affected with the morbid for¬ mations in question in an early stage, that, no matter what shape they assume, they are, in their primary state, possessed of a certain degree of transparency.

While there is the greatest diversity with regard to the colour

*

and magnitude of pulmonary tubercles, there is also the great¬ est variety in their degree of consistence. They are, for instance, sometimes almost as firm as cartilage, and at other times they are possessed only of a very slight degree of density. I have always found, when an opportunity has been afforded me of examining them before any reduction had taken place in their original density, that those which were situated at a considerable distance from each other, were possessed of a much greater degree of com¬ pactness of texture than such as were closely connected together. I am also led to believe, that they are considerably more solid in persons from thirty-five till fifty years of age, at the same stage of their growth, than they are from fifteen till thirty-five. In youth they would, in fact, seem to increase in size with much greater rapidity than they do after life is somewhat advanced; and I be¬ lieve it is an almost uniform law, both with new animal and vegetable formations, that, in proportion as their growth is quick, in the same proportion their texture becomes less and less firm. Now, if the same be applicable to the morbid growths in question, it must appear that in those cases where their increase in bulk is slow, their density will be, during their primary stage, much greater than when they grow in a more rapid manner.

The opinion of Laennec* respecting the more frequent occur¬ rence of tubercles in the right than the left lung, has been called in question by Louis, f who thinks the contrary of this is the case; that they take place much more frequently in the left than the

* AuscuU. Mediat.

f llechcrches sur la Phthisic.

right. It is very difficult to arrive at the truth in such an inves¬ tigation as this, unless it be carried on in a very large scale, and for a considerable length of time. Out of seventy cases of tu¬ berculous disease of the lungs, which I have had an opportunity of examining after death, I have found the right lung as fre¬ quently and as extensively affected as the left; and I cannot, therefore, agree with either of these eminent pathologists in con¬ sidering the one more liable to suffer in this way than the other. Notwithstanding I am of opinion that the right and left lung are equally liable to be affected with the formations in question, still in no individual case which is examined after death, will this be found to be correct; and it is only on that account, by comparing a great number of cases, the physician can say any thing definite with respect to the susceptibility of each.

With reference to the part of the lungs where tubercles are most liable to occur, I believe, however, it is admitted by almost all, that it is in their superior lobes. In early life, and in those cases where they are distinct from each other, this rule would certainly hold good ; but in persons who are advanced in life, or in cases of what has been den^ninated tubercular infiltration, I am inclined to think, the lower lobes are by far the most frequently and extensively affected. This has been the case, at least as far as I have had an opportunity of investigating the subject.

It was the prevailing opinion amongst physicians, till within the last few years, that tubercles were formed exclusively in the cel¬ lular tissue of the lungs. This was the opinion held by Laennec, and some others, relative to their seat. I am quite convinced, they are frequently formed in the cellular tissue ; but, while this is the case, I am at the same time satisfied, that their formation frequently occurs in the air tubes and air cells. This is, however, more especially the case with the latter. It would seem to me, altogether, relative to their formation, that it may take place at the same time in the air tubes, air cells, and cellular tissue.

Dr. Carswell thinks, the seat of the morbid deposits in ques-

Nature of Pulmonary Urn-sumption .

lion is the air tubes and air cells-* Notwithstanding the great importance which is to be attached to any opinion expressed by that gentleman, with regard to the various morbid affections of the pulmonary organs, still, I think, his opinions relative to the disease which I am now considering, are any thing at all but correct. In cases of tubercular infiltration, I believe, all the tissues of the lungs which I have just mentioned, may become the seat of the morbid deposits at one and the same time. I am of opinion, how¬ ever, that, when the tubercles assume the distinct form, it is more particularly in the cellular tissue their formation takes place.

The gray semi-transparent granulations which were first de¬ scribed by Baylejf- and afterwards considered by Laennec J and others to be the primary state of pulmonary tubercles, are sup¬ posed by Andral§ not to be of a tubercular nature, but rather the result of a kind of chronic inflammation. I am quite satisfied, however, he is not at all correct in this opinion; and I have no hesitation in asserting, that the granulations which are so fre¬ quently to be met with in the lungs, in the different stages of Consumption, are the commencement of the tubercles. I have had, in fever patients, very frequent opportunities afforded me of examining the lungs at the very earliest stage of tubercular formations, and there is no doubt left on my mind as to their transparent appearance for some time after their formation has taken place. In all the patients I have examined, where the disease was at an early stage, I never met with the opaque, with¬ out, at the same time, the semi-transparent tubercles ; and from the much greater size of the former than the latter, I was quite satisfied, that the smaller were in their primary, and the larger in their secondary state. In what is called tubercular infiltration, the solidified part had, in every instance where I examined it, but more particularly at an early stage, a somewhat transparent

* See Cyclopaedia of Practical Medicine ; art. Tubercle. f Rcchcrches sur la Phthisic. J Auscult. Mediat. § Precis d’Auct. Patlwlog.

B appearance. This fact I have been repeatedly enabled to verify, in my examinations of patients carried off by typhus fever, before the tubercular disease of the lungs had made much progress.

There is nothing connected with the subject of these morbid formations that has given rise to so much diversity of opinion, as, whether or not they are organized. It would appear to me, that one reason why there has been so much variety of opinion in this respect, is owing to the very different stages at which they have been examined. For instance, a person would arrive at a very different conclusion relative to their organic or inorganic nature, if he were to examine them with care at various stages. This is a thing, however, which is very seldom practicable, un¬ less a patient be carried off by some acute disease, such as typhus fever, before the morbid formations have been long in existence. From the extensive opportunities which I have enjoyed, of examin¬ ing not only pulmonary tubercles, but also those of the absorbent glands and other parts of the body, I have no hesitation in saying, that I consider them, during their primary or early stage, organ¬ ized bodies; but, in process of time, by a series of changes which they undergo, they are deprived of their vitality. I am, therefore, decidedly of opinion, that the growth of a tubercle, and its subsequent conversion into a caseous or liquid state, are as much entitled to the appellation of vital operations, as the forma¬ tion of a phlegmonous swelling and its subsequent conversion into a liquid or purulent state. When any of the absorbent glands which are situated about the neck, or in any other superficial situation, become tuberculous, it is no uncommon thing for them to be afterwards reduced to their natural size and structure. Now this is a thing which would not be at all likely to take place, if such increase of size was entirely owing to the deposition of inorganic particles.

I conceive that the first step in the formation of these morbid growths, is the effusion of a certain quantity of coagulable lymph, into whatever tissue or part is about to suffer from their presence. In the first place, this lymph is organized ; and after that has taken place, the increase in size”, and all the subsequent changes which occur, are accomplished by its own peculiar powers and actions. No matter what may be the nature of a new growth, or how dissimilar it be in its structure to the parts in which it is formed, still, if possessed of vital properties at all, it must be connected with them by that vascular union common to every organized part of the body. After tubercles are therefore once formed, they must grow by their own vital actions; but they must, at the same time, derive the materials of their growth from the surrounding parts. It would thus appear, that such new for¬ mations as those in question, and the surrounding tissues, must affect and be affected by the physical and vital conditions of each other.

Tubercles may acquire a considerable degree of density, and may also attain a great size, and afterwards remain in an inactive state for a great number of years. This is, however, unfortu¬ nately the case only in a very small proportion of patients; for we find they are mostly changed, with very great rapidity, into a liquid or purulent state, after they have arrived at a certain magnitude and density. I think it might be laid down as a rule, to which there are only a very few exceptions, that, in cases of tu¬ bercular infiltration, the change from the solid to the fluid state takes place much sooner, and is effected with much greater ra¬ pidity, than when the disease assumes the distinct form ; and again, when tubercles are very numerous, although quite distinct from each other, the same change will occur much earlier, and go on with much greater rapidity than when they are few in number, and remote from each other.

It is supposed by Dr. Carswell,* and various other eminent pathologists, that tubercles increase in size and density as inor¬ ganic bodies; and that they are again reduced to the fluid state, not by any changes which they can undergo as organized sub-

* Sec Cyclopaedia of Practiced Medicine ; art. Tubercle.

stances, but from certain impressions which are made upon them by the parts with which they are surrounded. I do not mean to say, that the state of the tissues, in their immediate neighbour¬ hood, may not hasten the process of suppuration or softening; for that is a thing to be expected, on account of their vital connec¬ tions with each other: but that inflammation and suppuration are essentially necessary in such tissues to the production of the changes in question, I cannot at all admit. If these morbid growths be examined at different stages, it will be seen that some of them have acquired a considerable degree of fluidity, when the surrounding parts manifest nothing like an inflammatory appear¬ ance. It would be easy to conceive the possibility of a fewdistinct tubercles being dissolved in the fluid yielded by the parts with which they are surrounded, in a state of inflammation and suppuration, provided these were really possessed of solvent pro¬ perties; but it would not be so easy to form an idea of the man¬ ner in which the greater part of an entire lung, wdien it is converted into a tubercular mass, could be changed to an almost fluid sfate by such a process. With reference to the softening of the morbid deposits in question, I am led to believe that it is immediately accomplished by their own actions; but, while this is the case, I am quite satisfied, that the state of the sur¬ rounding parts will either accelerate or retard such actions. The circumstance of tubercles being sometimes expectorated in an almost entire state, has, I think,. tended very much to favour the idea, that they possess no internal organization, by means of which they can change themselves, and that their solution is effected by means of the fluids yielded by the suppuration of the surrounding tissues.